Mandible Fracture Outcome Disparities in the Incarcerated Patient Population.

INTRODUCTION: Inmates represent a vulnerable health care population within the United States, with inconsistent access to surgical specialty care. Facial fractures are common among the incarcerated population, comprising approximately 14% of all traumatic injuries. However, few studies have evaluated facial fracture outcomes in this population. The aim of this study is to identify disparities in mandible fracture outcomes in the incarcerated population. METHODS: A retrospective review of all isolated traumatic mandible fractures at a single academic medical center from 2018 to 2023 was conducted. Mandible fractures were treated by plastic surgery, otolaryngology, or oral and maxillofacial surgery. Outcome measures such as rates of persistent malocclusion, motor deficits, surgical site infection, reoperation, and readmission were compared between inmate and civilian subgroups. RESULTS: A total of 205 patients (mean age, 33.1 years; 81.5% male) who were treated for isolated traumatic mandible fracture were included. A minority of patients (11.7%; n = 24) were inmates, whereas 88.3% (n = 181) were civilians. The mean time to operative intervention was 10.2 days in the incarcerated group and 4.4 days in the civilian group (P < 0.05). Persistent subjective malocclusion after surgery was noted in 20.8% (n = 5) of incarcerated patients and 7.2% (n = 13) of civilian patients (P < 0.05). There were no significant differences in rates of surgical site infection, reoperation, persistent motor deficits, or readmissions within 30 days. CONCLUSIONS: Incarcerated patients with traumatic mandible fractures have increased time to operative intervention and increased rates of subjective malocclusion postoperatively. Increased time to operative intervention may reflect barriers in access to specialty surgical care, which could adversely affect patient outcomes.

Benefits of Trimodality Therapy Compared with Systemic Therapy Alone in Male Patients with Stage IV Breast Cancer.

BACKGROUND: Male breast cancer (MBC) represents <1% of all breast cancer (BC) diagnoses. Recent publications in female stage IV BC have shown that surgical intervention has a survival benefit. This study aims to determine the impact of surgical intervention in men with stage IV BC and known estrogen (ER) and progesterone receptor (PR) status. METHODS: The National Cancer Database was used to identify 539 stage IV MBC patients with known ER/PR status from 2004 to 2017. Chi-square tests examined subgroup differences between the treatment modalities received. Overall survival (OS) was assessed using the Kaplan-Meier method. Multivariate Cox proportional hazard models examined factors associated with survival. RESULTS: The Kaplan-Meier estimation showed that ER-positive (ER+) and PR-positive (PR+) patients who received surgery, systemic therapy, and radiation (Trimodality) or systemic therapy and surgery (ST+Surg) had improved survival compared with systemic therapy alone (ST) [ER+, p < 0.003; PR+, p < 0.033]. For ER+ patients, the 5-year OS rates by treatment were: Trimodality, 40%; ST+Surg, 27%; and ST, 20%. For PR+ patients, the 5-year OS rates were: Trimodality, 39%; ST+Surg, 24%; and ST, 20%. The Cox proportional hazard model revealed a survival advantage in patients who received Trimodality compared with ST (hazard ratio 0.622; p < 0.002). The timing of systemic therapy in relation to surgery was not found to be significant. CONCLUSIONS: Trimodality therapy has a survival benefit in stage IV MBC patients with known ER+ status than in male patients who receive systemic therapy alone.

Head and Neck Free Flap Reconstruction in an Academic versus a Community Setting.

BACKGROUND: Head and neck free flap reconstructions are complex procedures requiring extensive resources, and have the potential to be highly morbid. As such, it is imperative that they should be performed in an appropriate setting, optimizing outcomes while limiting morbidity. The aim of this study is to identify any disparities in the treatment outcomes of patients undergoing head and neck free flap reconstruction by a single surgeon in an academic versus a community hospital setting. METHODS: A retrospective review of all patients who underwent head and neck free flap reconstruction for any indication by a single surgeon from 2009 to 2019 was conducted. All surgeries were performed at one of two hospitals: one academic medical center and one community hospital. Demographics and rates of partial or complete flap failure, medical complications, surgical complications, mortality, and other secondary outcomes were compared between the two settings. RESULTS: Ninety-two patients who underwent head and neck free flap reconstruction were included. Fifty-seven (62%) of free flap reconstructions were performed in the academic medical center, while 35 (38%) were performed in the community hospital. There were no significant differences in complete flap loss, either intraoperative or postoperative (p = 0.5060), partial flap loss (p = 0.5827), postoperative surgical complications (p = 0.2930), or medical complications (p = 0.7960) between groups. The in-hospital mortality rate was 0% (n = 0) at the university hospital as compared with 5.7% at the community hospital (p = 0.0681). The mean operative time was 702.3 minutes at the university hospital and 606.3 minutes at the community hospital (p = 0.0080). CONCLUSION: Head and neck free flap surgery can be performed safely in either an academic or a community setting, with no difference in primary outcomes of surgery. Preferential selection of either treatment setting should be based on consideration of patient needs and availability of auxiliary specialty services.

Benefits of Surgical Treatment of Stage IV Breast Cancer for Patients With Known Hormone Receptor and HER2 Status.

BACKGROUND: For the 6% of breast cancer patients with a diagnosis of stage IV disease, systemic therapy is the cornerstone of treatment, with an unclear role for surgery. Limited evidence exists to delineate treatment methods with regard to hormone receptor and human epidermal growth factor receptor 2 (HER2) status. METHODS: The National Cancer Database was used to identify 12,838 stage IV breast cancer patients with known hormone receptor and HER2 status from 2010 to 2015. Chi square tests examined subgroup differences between the treatment methods received. Using the Kaplan-Meier method, 5-year overall survival (OS) was assessed. Multivariate Cox proportional hazard models examined factors associated with survival. RESULTS: A survival advantage was noted for patients who received either systemic therapy and surgery (ST + Surg: hazard ratio [HR] 0.723; 95% confidence interval [CI] 0.671-0.779) or systemic therapy, surgery, and radiation (Trimodality: HR 0.640; 95% CI 0.591-0.694) (both p < 0.0001) compared with systemic therapy alone (ST). The HER2+ patients who received Trimodality or ST + Surg had a better 5-year OS rate than those who received ST (Trimodality [48%], ST + Surg [41%], ST [29%]; p < 0.0001). The sequence of chemotherapy in relation to surgery is significant, with the greatest survival advantage noted for recipients of neoadjuvant chemotherapy (NAC) compared with patients who had adjuvant chemotherapy when they had positive hormone receptor and HER2 status (HER2 + NAC: HR 0.477; estrogen receptor-positive [ER+] NAC: HR 0.453; progesterone receptor-positive [PR+] NAC: HR 0.448; all p < 0.0001). CONCLUSIONS: Surgery in addition to ST has a survival benefit for stage IV breast cancer patients with known hormone receptor and HER2 status and should be considered after NAC for patients with ER+, PR+, or HER2+ disease.

Clinical and cost efficacy of advanced wound care matrices in the treatment of venous leg ulcers: a systematic review.

BACKGROUND: Venous leg ulcers (VLUs) are hard-to-heal, recurrent and challenging to treat. Advanced wound care matrices (AWCMs) have been developed to supplement conventional therapies. These costly AWCMs warrant careful comparison as healthcare expenditures are subjected to increasing scrutiny. AIM: This study was designed to compare AWCMs in their ability to heal VLUs and their cost efficacy through a systematic review of randomised controlled trials (RCTs). METHOD: An organised search of Medline, Cochrane Library, Central and CINAHL databases identified RCTs that compared AWCMs to standard compression therapy in the healing of VLUs. Bias was assessed using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies. Eight studies analysing bilayered skin substitute (BSS) (Apligraf), dehydrated human amnion/chorion membrane (dHACM) (Epifix), human fibroblast-derived dermal substitute (HFDDS) (Dermagraft), extracellular wound matrix (ECM) (Oasis), advanced matrix (AM) (Talymed) and matrix wound dressing (MWD) (Promogran) met the inclusion criteria. RESULTS: Four studies reported significant improvement over standard therapy: BSS, dHACM, ECM and AM. Incremental cost per additional successful treatment was determined for each trial, ranging from $2593 (MWD) to $210,800 (HFDDS). CONCLUSION: Our consolidated analysis of eight major RCTs of AWCMs in the treatment of VLUs revealed a great variation in clinical and cost efficacy among these products. The included trials were inconsistent in methodology, and these limitations should be noted, but, in the absence of RCTs to compare these products, our systematic review may serve as a guide for practitioners who seek to optimise wound healing while considering cost efficacy.

Outcomes in Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis Patients Treated With a Medicine-Led Multidisciplinary Approach.

Patients with Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) have traditionally been treated in burn centers. Our burn center's approach differs by admitting these patients to a medicine service, with support from the burn team. The aim of this study was to determine whether SJS/TEN patients cared for with our system, with burn involvement but not burn admission, demonstrate equivalent outcomes. We conducted a retrospective review of all SJS/TEN patients admitted to the medicine service at a single academic medical center from 2009 to 2021. Outcome measures such as mortality, length of ICU stay, and total length of hospitalization were collected. The Severity-of-Illness Score for Toxic Epidermal Necrolysis (SCORTEN) was used to calculate expected mortality rates within the cohort. The observed mortality rates were then compared to the expected mortality rates. One hundred and twenty-six patients who were admitted for SJS/TEN were included (70 SJS, 40 SJS/TEN overlap, 16 TEN). The mortality rate for the entire cohort was 10.32% as compared to a 22.33% expected mortality rate (P = .010). The observed and expected mortality rates for SJS, SJS/TEN overlap, and TEN subgroups were 1.43% observed versus 10.22% expected (P = .029), 20.00% observed versus 35.83% expected (P = .133), and 25.00% observed version 44.06% expected (P = .264), respectively. Mortality rates in SJS/TEN patients admitted to medicine units are equivalent or decreased as compared to SCORTEN-predicted mortality rates. Admission of SJS/TEN patients to a medicine unit is appropriate providing there is burn team involvement in their care.

Natural History of 321 Flatfoot Reconstructions in Adult Acquired Flatfoot Deformity Over a 14-Year Period.

The purpose of this study was to report the natural history, demographics, and mechanisms of requirement for additional surgery in patients undergoing flatfoot reconstruction for adult acquired flatfoot. A total of 321 consecutive patients undergoing flatfoot reconstruction over a 14-year period were included (2002-2016). All procedures were performed by a senior orthopaedic foot and ankle surgeon at our institution. Demographic data, operative reports, clinic notes, and radiographs were available for review. Statistical analysis included calculation of relative risk (RR) ratios. The majority of patients were female (83.2%,) and most patients were overweight with a body mass index greater than 25 kg/m2 (56.4%). Patient comorbidities included diabetes (13.7%) and rheumatoid arthritis (3.7%). Additional surgery was required for 54 patients (16.8%). The most common reasons for additional surgery were the following: painful calcaneal hardware (57.4%), conversion to triple arthrodesis (16.7%), and wound healing complications (9.1%). An increased risk of need for additional surgery was associated with female gender (RR = 3.4; P = .0005), smoking status (RR = 1.9; P = .0081), and age (<60 years of age; RR = 1.8; P = .042). Although retrospective, the results provide insight into the natural history of this procedure. Clinicians may use these data to appropriately counsel patients who are at increased risk of requirement for additional surgery, such as smokers, women, and patients <60 years old, regarding treatment options.Levels of Evidence: Level IV.

Patient Outcomes in Mesenteric Venous Thrombosis Treated With Empiric Antibiotics.

BACKGROUND: Mesenteric venous thrombosis (MVT) is typically associated with poor prognosis. Although prophylactic antibiotics are sometimes given with the intent of limiting bacterial luminal load and translocation in patients with MVT, this approach has not been universally adopted. The aim of this study is to analyze whether utilizing antibiotics empirically in those with MVT improves patient outcomes and survival when compared to those who do not receive empiric antibiotics. METHODS: A retrospective review of patients admitted with MVT between 2002 and 2019 at a single academic institution was performed. Demographics and rates of mortality need for bowel resection, readmission, and Clostridium difficile (C. diff) infection were compared between patients treated with empiric antibiotics and patients not treated with antibiotics. RESULTS: Eighty-three patients (mean age 64.5 years and 55.4% male) who were admitted for MVT were included. Empiric antibiotics were utilized in 53% (n = 44) of MVT patients while 47% (n = 39) received supportive treatment without empiric antibiotics. Death occurred in 4 patients treated with antibiotics and 6 patients treated without antibiotics (9.1% vs. 15.3%, P = .50). Readmissions occurred in 12 patients (27.3%) treated with antibiotics and 10 patients (25.6%) not treated with antibiotics (27.3% vs. 25.6%, P = .87). C. diff infection occurred in 6 patients treated with antibiotics and in no patients not treated with antibiotics (13.6% vs. 0%, P = .03). CONCLUSIONS: Empiric antibiotic usage may not improve rates of mortality or hospital readmission in patients with MVT and may unnecessarily expose patients to an increased risk of C. diff infection.

Incidence, risk factors, and outcomes of early postoperative hyperglycemia in surgical patients: a protocol for a systematic review and meta-analysis.

BACKGROUND: Early postoperative hyperglycemia (POHG) is common and associated with poor postoperative outcomes. Currently, there is no systematic review and meta-analysis that addresses the knowledge gap of the incidence of POHG in surgical patients and that explores the associated risk factors and complications. The objective of this study will be to estimate the pooled incidence, risk factors, and clinical outcomes of early postoperative hyperglycemia in men and women globally. METHODS: We designed and registered a study protocol for a systematic review and meta-analysis of studies reporting the incidence of postoperative hyperglycemia (POHG). We will search PubMed (MEDLINE), Scopus, Web of Science, EMBASE, Cochrane Library, OVID (HEALTH STAR), OVID (MEDLINE), and Joana Briggs Institute EBF Database (from inception onwards). Randomized controlled trials and observational cohort studies reporting the incidence of POHG and conducted in surgical patients will be included. No age, geographical location, study design, or language limits will be applied. The primary outcome will be the incidence of POHG. Secondary outcomes will be risk factors and clinical outcomes of POHG. Two reviewers will independently screen citations, full text articles, and abstract data, extract data, and evaluate the quality and bias of included studies. Discrepancies will be resolved through discussion or consultation with a third researcher. The risk of bias and study methodological quality of included studies will be evaluated by the appropriate Cochrane risk of bias tool for randomized trials and Newcastle-Ottawa Scale for cohort studies. If feasible, we will conduct random effects meta-analysis with a logit transformation of proportions. We will report the probability of postoperative hyperglycemia as a measure of incidence rate, relative risk ratios (RR), and 95% confidence intervals to report the effects of the risk factors and postoperative outcomes. Additional analyses will be conducted to explore the potential sources of heterogeneity (e.g., age, gender, geographical location, publication year, comorbidities, type of surgical procedure). The Egger test and funnel plots will be used to assess small study effects (publication bias). DISCUSSION: This systematic review and meta-analysis will identify, evaluate, and integrate the evidence on the incidence, risk factors, and outcomes of early POHG in surgical patients. The results of this study can be used to identify populations which may be at particular risk for POHG. Future studies which use this information to better guide post-operative glycemic control in surgical patients could be considered. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration number CRD42020167138.

Doxorubicin, paclitaxel, and cisplatin based chemotherapy for the treatment of angiosarcoma: Two case reports.

INTRODUCTION: Angiosarcoma is a rare soft tissue malignancy of endothelial cells, generally associated with a poor prognosis. Due to its rarity, randomized trials are difficult to conduct and a consensus on the treatment of angiosarcoma has not been reached. The role, efficacy, and timing of chemotherapy in AS treatment remain uncertain, and as stated, no large-scale trials have been able to establish definitive recommendations. CASE DESCRIPTIONS: Here we describe the successful use of chemotherapy followed by radiation for a case of lower extremity angiosarcoma, and a case of breast angiosarcoma treated with neoadjuvant chemotherapy followed by surgical resection. Systemic therapy consisted of weekly doxorubicin, paclitaxel, and cisplatin. This regimen resulted in a full clinical remission in the first patient and a pathologic complete response in the second. DISCUSSION: These cases suggest that the use of the doxorubicin, cisplatin and paclitaxel combination could be an effective alternative to radical surgical excision in extremity sarcomas, and an effective adjuvant treatment to mastectomy in cutaneous radiation-associated angiosarcoma of the breast due to their independent efficacy against angiosarcoma. A randomized trial utilizing neoadjuvant combined doxorubicin, paclitaxel and cisplatin followed by either surgery or radiation, with endpoints assessing pathologic and overall response as well as progression free survival is warranted based on these cases. CONCLUSION: The role of neoadjuvant chemotherapy in the treatment of angiosarcoma should be reconsidered considering its ability to provide important prognostic information and improve the likelihood of curative surgery.

Regional, racial, gender, and tumor biology disparities in breast cancer survival rates in Africa: A systematic review and meta-analysis.

BACKGROUND: The survival rates from breast cancer in Africa are poor and yet the incidence rates are on the rise. In this study, we hypothesized that, in Africa, a continent with great disparities in socio-economic status, race, tumor biology, and cultural characteristics, the survival rates from breast cancer vary greatly based on region, tumor biology (hormone receptor), gender, and race. We aimed to conduct the first comprehensive systematic review and meta-analysis on region, gender, tumor-biology and race-specific 5-year breast cancer survival rates in Africa and compared them to 20-year survival trends in the United States. METHODS: We searched MEDLINE, EMBASE, and Cochrane Library to identify studies on breast cancer survival in African published before October 17, 2018. Pooled 5-year survival rates of breast cancer were estimated by random-effects models. We explored sources of heterogeneity through subgroup meta-analyses and meta-regression. Results were reported as absolute difference (AD) in percentages. We compared the survival rates of breast cancer in Africa and the United States. FINDINGS: There were 54 studies included, consisting of 18,970 breast cancer cases. There was substantial heterogeneity in the survival rates (mean 52.9%, range 7-91%, I2 = 99.1%; p for heterogeneity <0.0001). Meta-regression analyses suggested that age and gender-adjusted 5-year survival rates were lower in sub-Saharan Africa compared to north Africa (AD: -25.4%; 95% CI: -34.9 - -15.82%), and in predominantly black populations compared to predominantly non-black populations (AD: -25.9%; 95% CI: 35.40 - -16.43%). Survival rates were 10 percentage points higher in the female population compared to male, but the difference was not significant. Progesterone and estrogen receptor-positive breast cancer subtypes were positively associated with survival (r = 0.39, p = 0.08 and r = 0.24, p = 0.29 respectively), but triple-negative breast cancer was negatively associated with survival. Survival rates are increasing over time more in non-black Africans (55% in 2000 versus 65% in 2018) compared to black Africans (33% in 2000 versus 40% in 2018); but, the survival rates for Africans are still significantly lower when compared to black (76% in 2015) and white (90% in 2015) populations in the United States. CONCLUSION: Regional, sub-regional, gender, and racial disparities exist, influencing the survival rates of breast cancer in Africa. Therefore, region and race-specific public health interventions coupled with prospective genetic studies are urgently needed to improve breast cancer survival in this region.